Continuous Infusion Of Cisatracurium Research Articles

The effect of cisatracurium infusion on the energy expenditure of critically ill patients: an observational cohort study

BackgroundBoth overfeeding and underfeeding of intensive care unit (ICU) patients are associated with worse outcomes. A reliable estimation of the energy expenditure (EE) of ICU patients may help to avoid these phenomena. Several factors that influence EE have been studied previously. However, the effect of neuromuscular blocking agents on EE, which conceptually would lower EE, has not been extensively investigated.MethodsWe studied a cohort of adult critically ill patients requiring invasive mechanical ventilation and treatment with continuous infusion of cisatracurium for at least 12 h. The study aimed to quantify the effect of cisatracurium infusion on EE (primary endpoint). EE was estimated based on ventilator-derived VCO2 (EE in kcal/day = VCO2 × 8.19). A subgroup analysis of septic and non-septic patients was performed. Furthermore, the effects of body temperature and sepsis on EE were evaluated. A secondary endpoint was hypercaloric feeding (> 110% of EE) after cisatracurium infusion.ResultsIn total, 122 patients were included. Mean EE before cisatracurium infusion was 1974 kcal/day and 1888 kcal/day after cisatracurium infusion. Multivariable analysis showed a significantly lower EE after cisatracurium infusion (MD − 132.0 kcal (95% CI − 212.0 to − 52.0; p = 0.001) in all patients. This difference was statistically significant in both sepsis and non-sepsis patients (p = 0.036 and p = 0.011). Non-sepsis patients had lower EE than sepsis patients (MD − 120.6 kcal; 95% CI − 200.5 to − 40.8, p = 0.003). Body temperature and EE were positively correlated (Spearman’s rho = 0.486, p < 0.001). Hypercaloric feeding was observed in 7 patients.ConclusionsOur data suggest that continuous infusion of cisatracurium in mechanically ventilated ICU patients is associated with a significant reduction in EE, although the magnitude of the effect is small. Sepsis and higher body temperature are associated with increased EE. Cisatracurium infusion is associated with overfeeding in only a minority of patients and therefore, in most patients, no reductions in caloric prescription are necessary.

Effects of different methods of administration on clinical pharmacodynamics of cisatracurium during liver transplantation

Objective To evaluate the effects of different methods of administration on clinical pharmacodynamics of cisatracurium during liver transplantation.Methods Twenty-four ASA physical status Ⅲ patients of both sexes,aged 18-63 yr,weighing 60-88 kg,with body mass index of 20-30 kg/m2,scheduled for elective liver transplantation,were randomly divided into 2 groups (n =12 each):continuous infusion group (group C) and intermittent bolus injection group (group Ⅰ).The total intravenous anesthesia was used during surgery.When T1 recovered to 10％ of control height after induction of anesthesia,continuous infusion of cisatracurium was started with an initial rate of 1.5 μg· kg-1 · min-1,and the infusion rate was manually adjusted to maintain T1 at about 10％ in group C,and intermittent iv boluses of cisatracurium 0.03 mg/kg were given to maintain T1 ≤ 10％ in group Ⅰ.The use of muscle relaxants was stopped immediately after peritoneum closure.The consumption of cisatracurium per minute,time for T1 to recover from 10％ to 25％,recovery index and time for recovery of spontaneous breathing after surgery were recorded.Results Compared with group Ⅰ,the consumption of cisatracurium per minute was significantly reduced and the time for recovery of spontaneous breathing after surgery was shortened (P ＜ 0.05),and no significant changes were found in the time for T1 to recover from 10％ to 25％ and recovery index in group C (P ＞ 0.05).Conclusion Compared with intermittent bolus injection,continuous infusion of cisatracurium during liver transplantation is helpful in improving the clinical potency of the muscle relaxant and in reducing the occurrence of complications during anesthesia recovery period. Key words: Infusions, intravenous ; Injections, intravenous ; Neuromuscular nondepolarizing agents ; Liver transplantation ; Pharmacology, clinical

The role of neuromuscular blockers in ARDS

Neuromuscular blocking agents (NMBAs) are part of the pharmaceutical arsenal employed to treat acute respiratory distress syndrome (ARDS). However, their use remains controversial because the potential benefits of these agents are counterbalanced by possible adverse effects. This review summarizes advantages and risks of NMBAs based on the most recent literature. NMBAs have been shown to improve oxygenation during severe ARDS in three randomized controlled trials. The most recent results demonstrated that NMBAs decrease 90-day in-hospital mortality, particularly in the most hypoxaemic patients. NMBAs have not been shown to be an independent risk factor of neuromyopathy in most studies. NMBAs are commonly used in ARDS (25-55% of patients), but the benefits and the risks of using these agents are controversial. Recent data suggest that a continuous infusion of cisatracurium during the first 48 h of ARDS, particularly for patients with a P(a)O(2)/F(i)O(2) ratio less than 120, can decrease 90-day in-hospital mortality. NMBAs do not appear to be an independent risk factor for ICU-acquired weakness if they are not given with corticosteroids or in patients with hyperglycaemia.

Large bolus dose vs. continuous infusion of cisatracurium during hypothermic cardiopulmonary bypass surgery

Background and objective: We investigated whether a high bolus dose of cisatracurium (8× ED95) given at induction can provide muscle relaxation for the major part of a cardiac procedure with hypothermic cardiopulmonary bypass, avoid important postoperative residual curarization and cause no waste of product. Methods: Twenty patients were randomly assigned either to Group 1 (n = 10) or Group 2 (n = 10). Those in Group 1 were given cisatracurium in a high bolus dose (0.4 mg kg−1). Those in Group 2 received cisatracurium 0.1mg kg−1 at induction followed after 30 min by a continuous infusion of cisatracurium. As an escape medication in case of patient movement, a bolus dose of cisatracurium 0.03 mg kg−1 was given. Results: In Group 1 (large cisatracurium bolus dose), the clinical duration of effect (until T1/T0 = 25%) was 110 min. Six of 10 patients in Group 1 required additional boluses of cisatracurium intraoperatively. Four of these six had received an additional bolus near the end of surgery and had a train-of-four (TOF) ratio = 0 at the end. The other four patients in Group 1 had a final TOF ratio >0.9. In Group 2 (continuous cisatracurium infusion), only two patients had a TOF ratio >0.9 at the end of surgery, no patient moved and none received additional boluses. The total amount of cisatracurium used in the bolus and infusion Groups was 34.5 ± 7.8 and 21.3 ± 5.7 mg, respectively (P = 0.0004). Conclusions: For continued neuromuscular block during hypothermic cardiac surgery, a high bolus dose of cisatracurium appears to be safe, although it is not an alternative to a continuous infusion, as its neuromuscular blockade does not cover the intraoperative period and a high incidence of movements occurs. In the patients who received a high bolus dose of cisatracurium, postoperative residual curarization appeared after additional boluses had been given. The consumption of cisatracurium by high bolus was significantly greater than with continuous infusion.

Large bolus dose vs. continuous infusion of cisatracurium during hypothermic cardiopulmonary bypass surgery

We investigated whether a high bolus dose of cisatracurium (8x ED95) given at induction can provide muscle relaxation for the major part of a cardiac procedure with hypothermic cardiopulmonary bypass, avoid important postoperative residual curarization and cause no waste of product. Twenty patients were randomly assigned either to Group 1 (n = 10) or Group 2 (n = 10). Those in Group 1 were given cisatracurium in a high bolus dose (0.4 mg kg(-1)). Those in Group 2 received cisatracurium 0.1 mg kg(-1) at induction followed after 30 min by a continuous infusion of cisatracurium. As an escape medication in case of patient movement, a bolus dose of cisatracurium 0.03 mg kg(-1) was given. In Group 1 (large cisatracurium bolus dose), the clinical duration of effect (until T1/T0 = 25%) was 110 min. Six of 10 patients in Group 1 required additional boluses of cisatracurium intraoperatively. Four of these six had received an additional bolus near the end of surgery and had a train-of-four (TOF) ratio = 0 at the end. The other four patients in Group 1 had a final TOF ratio >0.9. In Group 2 (continuous cisatracurium infusion), only two patients had a TOF ratio >0.9 at the end of surgery, no patient moved and none received additional boluses. The total amount of cisatracurium used in the bolus and infusion Groups was 34.5 +/- 7.8 and 21.3 +/- 5.7 mg, respectively (P = 0.0004). For continued neuromuscular block during hypothermic cardiac surgery, a high bolus dose of cisatracurium appears to be safe, although it is not an alternative to a continuous infusion, as its neuromuscular blockade does not cover the intraoperative period and a high incidence of movements occurs. In the patients who received a high bolus dose of cisatracurium, postoperative residual curarization appeared after additional boluses had been given. The consumption of cisatracurium by high bolus was significantly greater than with continuous infusion.

Dose requirements and recovery profile of an infusion of cisatracurium during liver transplantation

Study Objective: To examine the dose requirements and recovery profile of an infusion of cisatracurium during liver transplantation. Design: Open-label, descriptive study. Setting: University hospital. Patients: 6 ASA physical status III and IV patients with end-stage liver disease, undergoing liver transplantation. Interventions: Neuromuscular transmission was monitored electromyographically. After recovery of T 1 /T 0 to 10%, cisatracurium was infused at an initial rate of 1.5 μ g/kg/min. The infusion rate was adjusted to maintain T 1 /T 0 at 10%. At the end of surgery, spontaneous recovery from the neuromuscular block was awaited. Measurements and Main Results: The infusion rate of cisatracurium was 1.6 ± 0.4 μ g/kg/min. Before the anhepatic phase, this rate was 1.5 ± 0.4 μg/kg/min; during the anhepatic phase it was 1.7 ± 0.5 μg/kg/min; and after reperfusion it was 1.9 ± 0.4 μ g/kg/min. There was a significant difference between the cisatracurium infusion rates before and after the anhepatic phase (p < 0.05). Following termination of the infusion, the time to 25% recovery of T 1 /T 0 was 19.2 ± 6.1 minutes, the recovery index (25% to 75%) was 28.8 ± 7.0 minutes, and the time for the train-of-four (TOF) ratio to reach 0.7 was 50.2 ± 7.1 minutes. The time for the TOF ratio to reach 0.9 was 61.4 ± 6.6 minutes. There was no difference in body temperature or pH during the consecutive stages of transplantation. Conclusions: The infusion dose requirement for cisatracurium during liver transplantation tended to be higher than previously reported in healthy patients; recovery appeared prolonged. In continuous infusion of cisatracurium during liver transplantation, the tendency toward higher dose requirements, the protracted duration of infusion, the non-Hofmann elimination and/or other pharmacokinetic changes during transplantation might influence recovery from the neuromuscular block. Potential temperature or pH change during surgery seemed irrelevant in explaining the delayed recovery.

The pharmacokinetics of cisatracurium in patients with acute respiratory distress syndrome.

Continuous neuromuscular blockade is often necessary in patients being treated for acute respiratory distress syndrome (ARDS) to optimize oxygenation. In this study, neuromuscular blockade (no response to two responses at the train-of-four stimulation at the orbicularis oculi muscle) was achieved in six patients with ARDS by a continuous infusion of cisatracurium. The plasma concentration of cisatracurium during the infusion averaged 1.00 (0.25-1.45) microg/mL, expressed as median (range). The clearance and half-life were 6.5 (3.3-7.6) mL. min(-1). kg(-1) and 25 (16-48) min, respectively. The laudanosine plasma concentrations were 0.70 (0.12-1.20) microg/mL. The pharmacokinetic variables of cisatracurium are similar to those of patients without organ failure undergoing elective surgery. Plasma laudanosine levels always remained well less that those associated with seizure activity in animal models. Long-term infusion of cisatracurium was not associated with any side effects. Cisatracurium is a suitable muscle relaxant when deep and continuous levels of muscle relaxation are required in patients treated for ARDS. We studied the pharmacokinetics of cisatracurium in six patients treated for respiratory distress syndrome by continuous muscle relaxation. A deep degree of neuromuscular blockade corresponding to abolition of two responses at the orbicularis oculi to train-of-four stimulation was obtained in all patients. The pharmacokinetic variables observed in these severely ill patients were similar to those of anesthetized patients. No accumulation of laudanosine was seen. Cisatracurium appears to be suitable when continuous muscle relaxation is required in critically ill patients.

Récupération du bloc neuromusculaire après perfusion continue de cisatracurium chez l’insuffisant rénal

Objective: Study of the recovery of neuromuscular block after continuous infusion of cisatracurium in patients with renal dysfunction. Study design: Prospective case-control study. Patients: Forty adult patients scheduled for urological surgery were assigned to two groups according to the creatinine clearance (CC) as a measure of the renal function : group IR (CC < 60 mL·min –1) or group NR (CC ≥ 60 mL·min –1). Methods: After premedication with hydroxyzine, anaesthesia was induced with propofol, sufentanil and cisatracurium (0.15 mg·kg –1), and maintained using isoflurane, sufentanil and a continuous infusion of cisatracurium (0.12 mg·kg –1·h –1) adjusted for maintained a post-tetanic count ≤ 5. Neuromuscular transmission was monitored at the adductor pollicis using accelerography (TOF Gard®). Onset and recovery times in both groups were compared using Studentˈs t test. Results: Infusion time and total dose of cisatracurium were comparable in both groups. Onset times were 3.9 ± 0.8 min and 3.5 ± 0.6 min in groups IR and NR respectively. After the infusion, the time to train-of-four ratio of 0.8 were not different in both groups : 77 ± 18 min (group IR) and 73 ± 13 min (group NR). However, the spontaneous recovery intervals 25 %-75 % were delayed in group IR (20 ± 9 min vs 14 ± 5 min p < 0.05). Conclusion: There are minor differences in the pharmacodynamics of cisatracurium between patients with normal or impaired renal function. Nevertheless, a marked inter-individual variability in the recovery parameters was observed in patients with renal dysfunction.

The Effects of Magnesium-Pretreatment on the Neuromuscular Blocking Actions of Cis-atracurium in the Cat

Background : Cis-atracurium is more potent, and less likely to release histamine and has better autonomic and cardiovascular stability, compared to atracurium. It is eliminated mainly by Hofmann reaction and produces less amounts of laudanosine, the first metabolite which has the CNS stimulating property. However, drug interactions with several ions, such as magnesium that is popular in treating eclampsia have not yet to be known. Methods : Using sciatic nerve-anterior tibialis preparation in the cat, we tried to find out whether cis-atracurium has the cumulation effect by administering four consecutive 100 g/kg of cis-atracurium. After confirming that the cis-atracurium had no cumulation effect, we proceeded the dose-response study to find out the ED50, ED95 and action duration of cis-atracurium in control group(II) and magnesium-pretreated group(III). After cumulative dose -response study, in the half of the group II and III, the infusion rate to maintain 90% twitch depression at least for 20 minutes was obtained, and afterwards, the recovery index was measured after the discontinuation of infusion. In the other half of the group II and III, while maintaining 90% twitch depression at least for 20 minutes through continuous infusion of cis-atracurium, we administered the 10 g/kg of neostigmine to measure the onset time, action duration and antagonism effect of the drug. Results : The cis-atracurium did not have the cumulation effect and in group III, ED50 and ED95 were decreased significantly from 234 82 g/kg to 103 18 g/kg and from 399 123 g/kg to 173 28 g/kg, respectively, compared with group II. The action duration of cis-atracurium ED95 in group III(190 52 sec) was significantly longer than in group II(143 29 sec). The infusion rate of cis-atracurium to maintain 90% twitch depression was significantly higher in group II in the spontaneous recovery and the neostigmine-induced antagonism(6.63 2.37 and 4.47 1.58 g/kg/min), respectively. Conclusion : The cis-atracurium do not have the cumulation effect. And, the magnesium potentiates the neuromuscular blocking actions of cis-atracurium. However, it has no effect on the antagonism action of neostigmine. (Korean J Anesthesiol 1998; 35: 215∼222)